Bursary Application Form
2013
Application for Unisa Foundation Bursary Schemes
Postgraduate Diploma
Yes
No
Honours
Yes
File no (for Office use only)
No
Application schedule
30 September – 21 December 2012
(Only SA citizens need apply)
*Only one application per academic year
FOR OFFICE USE ONLY
Total annual income
Number of lawful H/H
Number of tertiary students
Remaining term of sentence
Comments
Screened by
Application form accepted by
1.
Personal particulars
Mr
Title
Mrs
Initials
Ms
Surname
Identity number
Do you have any other
forms of funding?
Student no
Yes
No
If yes, please state the sponsor
Name of institution
State your highest qualification
Year of completion
Are you under financial administration order (insolvency) for unpaid debt?
Yes
No
Have you been declared mentally unfit by a court of law to enter into any legal agreement?
Yes
No
Marital status
Single
Married
If married
Widowed
Divorced
In community of property
Ante nuptial contract (ANC)
Prenuptial contract (PNC)
*Please supply us with an applicable certified copy: marriage certificate, ANC, PNC, death certificate (widowed), divorce decree
Prison student
2.
Yes
No
If yes, please attach the prisoner’s profile from authorities indicating term of sentence, years already
served and remaining years to be served.
Employment details
Yes
Are you employed?
If yes, please complete section 2.1. If no, please complete sections 3 or 3.1.
2.1
Applicant’s employment details (attach certified proof of income not older than three months)
Name of employer
Address
Tel number
Monthly
Salary
Wages
Other
Weekly
*If married please complete section 3.1 with spouse’s employment details
1
No
3.
Details of parent/s for a dependant’s application
Please attach certified copies of ID, death certificate or divorce decree. If one or both parents are unknown, the guardian must confirm
this in an affidavit (not the student).
Please attach latest pay slip if employed, last 3 months’ bank statements and an affidavit if self-employed or unemployed.
Father
Mother
Name & Surname
ID number
Residential address
Employer’s name
Employer’s address
Employer’s tel number
Salary
Type of Income
Wages
Other
3.1
Legal guardian/spouse (p[lease attach latest pay slip if employed, last 3 months’ bank statements and an affidavit if selfemployed or unemployed)
Name & Surname
Type of Income
ID number
Monthly
Salary
Residential Address
Employer/s name
Type of income
Weekly
Monthly
Wages
Weekly
Employer’s address
Employer’s tel number
4.
Monthly
Other
Weekly
Particulars of next of kin: mother, father, sister, brother, cousin, partner, aunt or uncle
Surname
Initials
Title
Relationship to applicant
Postal address
Telephone number
5.
Cell number
Particulars of lawful household (e.g. parent/s, guardian, other dependents starting with applicant):
NB: Please use a separate page if space provided below is insufficient
Attach certified copies of RSA identity documents or birth certificates of all members of lawful household
Name
Surname
ID Number
Relationship to
applicant (1)
Age
Currently busy with
(2)
(1) Spouse/partner/brother/sister/daughter/son/uncle/aunt/grandparent/other
(2) Primary school/secondary school/out of school/unemployed/employed/university (of technology)/FET college/other
Please attach certified copies of proof of income for employed members of household stated in section 5; excluding members already
mentioned in sections 3 and 3.1.
6.
Declaration
I declare that I have read and understood the contents of this bursary application form, and information supplied by me is true and correct. I also
understand that should any of the information/documents herein be proved to be incorrect or falsified, disciplinary action will be taken against me.
……………………………………………………………………
……………………………………………………..
Student’s signature
Date
2
0
